sms pendleton k12 or - DOC by fDQ7Zq

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									                                                                                                                                2012-2013
                                       Pendleton School Based Health Center

Pendleton High School
                                                      Student Registration                                        Sunridge Middle School
1800 N.W. Carden Ave.                                                                                             700 S.W. Runnion Ave
Pendleton, OR 97801                    Please fill out FRONT and BACK of form                                     Pendleton, OR 97801
541-966-3857                                                                                                      541-966-3432


Today’s Date:          /   /

Student Name:
                       Last                      First                            M.I.
Address:                           Home Phone:            -     -
City:                          State: OR          Zip:
DOB:        /   /               Age:             Grade:                 Sex:      Male          Female

Ethnicity- Please check all that apply :   Hispanic      Non-Hispanic     Other
Race - Please Check all that apply
    White                  Pacific Islander           N. America / N. Alaskan              More than one Race
    Black                  Asian                      Hispanic                             Other:

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Student Health Information
ALLERGIC TO MEDICATION:                     Yes /      No What Medication?

Chronic medical illness (past/present):
Current Medications:
Other important health history:
Primary Care Provider:
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Please place a check mark next to the medications listed below that the nurse or nurse practitioner may administered to your child
without calling first for permission. Generic over-the counter medications are available at the Health Centers.

    Tylenol (Acetaminophen)                Advil (Ibuprofen)              Day Quil             Claritin 24-Hour (Loratadine)

    Hydrocortisone Cream                   Benadryl (Diphenhydramine HCI)                      A&D Ointment

    Nasal Decongestant PE (Phenylephrine Hydrochloride)                  Tums                  Viscous Lidocaine Oral 2%

    Bacitracin/Triple Antibiotic Ointment                           Orajel/Anbelsol           Albuterol MDI
     Auralgan Eardrops (antipyrine benzocaine)
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Would you like your child to have a Well Child Physical:                           I decline             I accept-make an appointment

Would you like your child to have a Sports Physical:                              I decline             I accept-make an appointment


                                           BACKSIDE – Turn Over

                                                         Office Use Only:
 Well Child Physical packet given: _______ Sports Physical sheet given: _______  Immunization Packet: _______
 Notice of Privacy Practices & Rights & Responsibilities: ________

DOB: _______________ ID#: ____________________ Name: _______________________________
Do you have insurance:             Yes       No       Unsure
If yes, please check type:          Private Insurance payment                          Oregon Health Plan           Unknown

Name of Insured Person            Insured Person’s DOB:            /    /

Employer:           Insurance Company:

Insurance ID#:      Group Name or ID#:
Insurance Company Address & Phone #:
Do you have secondary insurance:                   Yes                 No

Consent to Bill: I authorize the release of any medical and protected health information necessary to process this claim and authorize
payment of medical benefits for services by the Pendleton School Based Health Center.

Signature of Authorized Person: ______________________________________________

Charges: Insurance will be billed for Immunization(s) & services provided by the Nurse Practitioner. Any services provided outside of the
School Based Health Center, such as pharmacy, radiology, or laboratory, are the responsibility of the parent or guardian.
Our privacy obligations: Pendleton School Based Health Centers is required by law to maintain the privacy of your health information. A
copy of the Notice of Privacy Practices & Student Rights & Responsibilities are available upon request by contacting the School Based Health
Center at the appropriate school.

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Parent/Guardian Information: 
Name:                                                                       Name:
Relationship:                                                               Relationship:

Phone #’s: H  /    /          W      /    /        C       /   /            Phone #’s: H    /   /    W      /   /     C   /   /
Emergency Contact:
Name:                              Phone:      /       /           Relationship:
Please list the Names, Age, and Relationship of everyone in the household:




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Parental Consent:
I authorize        to receive physical and/or mental health services from the School Based
                (Student Name)
Health Center. I also authorize and give permission to the School Based Health Center to contact my child's personal care physician to
share medical information regarding ongoing medical needs. Pertinent medical information may be shared with the school facility.
The School Based Health Center will not dispense condoms, birth control devices, or provide abortion counseling.
 This consent form will remain in effect until such a time a written decision to revoke this consent is given to the health center, or if the
student withdraws from school.

*We support and encourage parental involvement in decisions about a child’s health care. Oregon State Law require s a parent or
guardian’s signature for medical treatment for students less than 15 years of age with the exception of family planning information and
sexually transmitted illnesses.

**Mental health services, including drug and alcohol issues, require parental permission of the child if less than 14 ye ars of age.

Parent/Legal Guardian Signature: __________________________________________________ Date: _____________

                                                               THANK YOU!!              ☺
DOB: __________________          ID#: ________________________                    Name: _________________________________________
SBHC Revised : JF 04-11 (rev 05/12)

								
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